HospitalInspections.org

Based on observation, document review and interview, the Governing Body failed to:
A. protect and promote patient rights.
1. One of one patients (#14) was not provided the right to make an informed decision regarding care.
Refer to Tag A0131
2. The patient grievance process was not followed.
Refer to Tag A0122, A0123
3. Patients receiving dialysis treatment were not provided care in a safe setting.
Refer to Tag A0144
4. STAT/one time orders for chemical restraints were being written as a PRN (as needed) order with a possibility of the patient receiving multiple doses of psychotropic medications which could cause serious harm or potential death in 1(#54) of 3 (#54-56) charts reviewed.
Refer to Tag A0144
5. Hazards were found in the behavioral unit that posed the likelihood of harm to patients.
Refer to Tag A0144

B. ensure organization and supervision of Nursing Services
1. Nursing services failed to ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures.
Refer to A0386
2. Nursing Services did not provide clear lines of authority and responsibility for staffing of the Observation Unit.
Refer to A0386
3. 3 of 3 registered nurses (#12, #21 and #22) did not have documentation of current licensing in their personnel files.
Refer to A0394
4. Nursing Services failed to ensure registered nurses provided continuous and accurate evaluation of patients on suicide precautions and patients who were at risk for nutritional complications. This deficient practice was found in 5 of 5 sampled patients (Patient #'s 11, 17, 18, 19, and 20).

Refer to A0395

5. Nursing staff failed to administer medication using procedures specified by hospital policy for "Enteral Feedings/ Medications" in 1 patient (Patient #16) of 1 patient observed.

Refer to A405

6. Nursing failed to ensure 1 of 1 sampled patients receiving blood transfusions received continuous monitoring (Patient #14).
Refer to A409

C. ensure patients with contagious infections and who had a recent history of contagious infections were placed in contact isolation timely. The facility failed to ensure Infection Control policies were implemented to ensure there was a sanitary environment in 7 of 7 patient care areas (Emergency Department, Oncology unit, Pediatrics unit, Intensive care unit, Sleep center and Off-site Emergency Department, and Behavioral Health Unit).

Refer to tag A0747, A0749
D. provide Surgical Services in accordance with acceptable standards of practice.
1. The facility failed to ensure that surgical technologists working in the surgical department were certified to ensure the health and safety of the surgical patients that were receiving surgical procedures at the facility.
2. The facility failed to monitor humidity and temperature in the surgical department where surgical procedures were performed and sterile instruments were stored.
3. The facility failed to monitor and provide a safe and sanitary environment to minimize the transmission of infectious agents in 3 of 7 surgical areas observed.
Refer to Condition Tag A940

Based on record review, document review and interview, the facility failed to:


A. ensure the patient grievance process was followed and contact was made with the complainants within 7 business days in 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
Refer to Tag A0122


B. ensure the patient grievance process was followed and a final written response was sent to the complainant within 30 business days in 1 (patient #40) of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
Refer to Tag A0123


C. ensure the right to make an informed decision was provided regarding care in 1 of 1 sampled patients (Patient #14).
Refer to Tag A0131

D. ensure staff performed conductivity readings with an independent device before each dialysis treatment and compare them to the dialysis machine reading. Citing 1 (#5) out of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

Refer to Tag A0144


E. ensure staff corrected an abnormal conductivity between the phoenix meter and the dialysis machine citing 1 (#5) of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

Refer to Tag A0144


F. ensure staff maintained evidence of monthly logs for all phoenix meters, when in service or noting they are out of service. Citing 1 of 2 phoenix meters.

Refer to Tag A0144


G. ensure staff conducted the second level calibration of the phoenix meter at least monthly for 2 (03773K and P35315) of 2 (03773K and P35315) phoneix meters. The staff also failed to maintain all the logs for 1 (P35315) of 2 (03773K and P35315) phoenix meters.

Refer to Tag A0144


H. ensure the staff changed the dialysate filters on the dialysis machines at least every 90 days. Citing 4 (OKOS-162237, OKOS-162328, OKOS-162271 and OKOS-162316) of 7 (OKOS-162237, OKOS-162328, OKOS-162271, OKOS-162316, OKOS-162342, OKOS-162337, OKOS-162342) dialysis machine records reviewed.

Refer to Tag A0144


I. conduct weekly culture and endotoxin weekly x ' s 4 until they received 4 weeks of consecutive negative tests when replacing the membranes in the main water system (RO). Citing replacement of membranes for 1 of 1 main RO's.

Refer to Tag A0144


J. ensure they had documented evidence of the Hepatitis B immunizations for all clinical staff; by having proof of their Hepatitis B antibody conversion, non-responder status, or have administered the immunization. Citing 13 staff employee health files reviewed (#7, #8, #10, #11, #19, #20, #43, #47, #50, #51, #52, #53, and #54) of #18 staff (#7, #8, #10, #11, #12, #13, #14, #19, #20, #21, #22, #43, #47, #50, #51, #52, #53, and #54) employee health records reviewed.

Refer to Tag A0144


K. ensure the Hospital Quality Improvement Committee reviewed the contracted dialysis service including the operation of the water system, dialysis equipment maintenance, phoenix meter logs, chlorine logs and all other daily operation of the dialysis unit. The minutes must document compliance, plan of action when they identify corrective action taken. In addition there was no evidence the reports of culture and endotoxin (LAL) reports were trended over time through the hospital's Quality Improvement meeting. Citing 9 (August 2015- April 2016) of 9 months (August 2015- April 2016) Dialysis Quality Improvement Meeting minutes requested.

Refer to Tag A0144


L. ensure the staff kept the floor of the water room clean.

These findings had the likelihood to cause harm to all patients by exposing them to unsafe dialysate, increased risk of infection by failure to maintain the water room in a clean manner and failure to conduct the appropriate cultures.

Refer to Tag A0144

M. ensure STAT/one time orders for chemical restraints were administered only one time. The facility also failed to ensure the one time order was not written or used as a PRN (as needed) medication, with a possibility of the patient receiving multiple doses of psychotropic medications, that could cause serious harm or potential death in 1 (#54) of 3 (#54-56) charts reviewed.
Refer to Tag A0144
This deficient practice was determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

N. ensure the behavioral unit was free of safety hazards that could be used to cause harm to patients.

Refer to Tag A0144

Based on record review and interview, the facility failed to ensure the patient grievance process was followed and contact was made with the complainants within 7 business days in 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
A review of 5 (patients #36, #38, #39, #40 and #41) out of 6 (patients #36, #37, #38, #39, #40 and #41) written "Complaint Records" revealed the facility did not make contact with the complainants within 7 business days to acknowledge receipt of the grievances.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The patient, a family member or the responsible party will be contacted within 7 business days of the concern, complaint or grievance received in writing to document the contact, to acknowledge receipt of the concern, complaint or grievance and/or answer the complaint.
An interview with staff #6 and #39, confirmed the above findings.

Based on record review, document review and interview, the facility failed to ensure the patient grievance process was followed and a final written response was sent to the complainant within 30 business days in 1 (patient #40) of 6 (patients #36, #37, #38, #39, #40 and #41) grievances reviewed.
Review of patient #40's Complaint Record revealed the written grievance was received by the facility on 02/25/2016. The final resolution letter was sent to the complainant 51 business days later on 05/06/2016.
A review of the facility's policy titled, "Complaint and Resolution Process" revealed the following information:
" ...The final written response must be sent to the complainant within 30 business days."
An interview with staff #6 and #39, confirmed the above findings.

Based on interview and record review the facility failed to ensure the right to make an informed decision was provided regarding care in 1 of 1 sampled patients (Patient #14).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

Review of the clinical record of Patient #14 revealed he was a 69 year old male who presented to the Emergency Department on 05/14/2016 at 4:00 a.m.. Patient #14 presented with diagnoses which included gastrointestinal bleeding and altered mental status.
Review of the clinical record revealed Patient #14 received blood transfusions and had a bedside EGD (esophagogastroduodenoscopy) while in the hospital.
Review of the clinical record revealed a consent for treatment which was not signed by the patient or patient representative. There was a consent for anesthesia, flexmoid sigmoidoscopy, esophagogastroduodenoscopy, and blood transfusion which had the documentation "medical necessary" in the section designated for the patient/other responsible person's signature.
Review of Patient #14's record revealed a phone number and name of a responsible person listed. There was no documentation on the consents or in the record showing there were attempts made to notify the responsible party to obtain consent prior to treatment.
Staff #83 confirmed the problems with the consents.

Review of the facility policy named "Informed Consent, Policies On" revealed the following:

"Consent will be obtained in writing prior to performing surgical procedures, nonsurgical invasive, diagnostic and /or therapeutic procedures, intravenous injection of contrast material, central line insertions (unless in conjunction with anesthesia) and all procedures in which anesthesia or sedation is used.
Exceptions: In emergency treatment, when the individual's welfare or safety is at risk and substitute consent from authorized individual cannot be obtained the treating physician must document in the progress notes the medical necessity of the treatment or procedure.
9. If a patient is comatose, incapacitated, or otherwise mentally or physically incapable of communication, an adult surrogate, who has decision making capacity and is available after a reasonably diligent inquiry may give consent."

Based on record review and interview, the facility failed to:

A. ensure staff performed conductivity readings with an independent device before each dialysis treatment and compare them to the dialysis machine reading. Citing 1 (#5) out of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

B. ensure staff corrected an abnormal conductivity between the phoenix meter and the dialysis machine citing 1 (#5) of 5 (#4, #5, #12, #43 and # 44) medical records reviewed.

C. ensure staff maintained evidence of monthly logs for all phoenix meters, when in service or noting they are out of service. Citing 1 of 2 phoenix meters.

D. ensure staff conducted the second level calibration of the phoenix meter at least monthly for 2 (03773K and P35315) of 2 (03773K and P35315) phoenix meters. The staff also failed to maintain all the logs for 1 (P35315) of 2 (03773K and P35315) phoenix meters.

E. ensure the staff changed the dialysate filters on the dialysis machines at least every 90 days. Citing 4 (OKOS-162237, OKOS-162328, OKOS-162271 and OKOS-162316) of 7 (OKOS-162237, OKOS-162328, OKOS-162271, OKOS-162316, OKOS-162342, OKOS-162337, OKOS-162342) dialysis machine records reviewed.

F. conduct weekly culture and endotoxin until they had 4 weekly consecutive negative tests when replacing the membranes in the main water system (RO). Citing replacement of membranes for 1 of 1 main RO's.

G. ensure they had documented evidence of the Hepatitis B immunizations for all clinical staff; by having proof of their Hepatitis B antibody conversion, non-responder status, or have administered the immunization. Citing 13 staff employee health files reviewed (#7, #8, #10, #11, #19, #20, #43, #47, #50, #51, #52, #53, and #54) of 18 staff (#7, #8, #10, #11, #12, #13, #14, #19, #20, #21, #22, #43, #47, #50, #51, #52, #53, and #54) employee health records reviewed.

H. ensure the Hospital Quality Improvement Committee reviewed the contracted dialysis service including the operation of the water system, dialysis equipment maintenance, phoenix meter logs, chlorine logs and all other daily operation of the dialysis unit. The minutes must document compliance, plan of action when they identify corrective action taken. In addition there was no evidence the reports of culture and endotoxin (LAL) reports were trended over time through the hospital's Quality Improvement meeting. Citing 9 (August 2015- April 2016) of 9 months (August 2015- April 2016) Dialysis Quality Improvement Meeting minutes requested.

I. ensure the staff kept the floor of the water room clean.

These findings had the likelihood to cause harm to all patients by exposing them to unsafe dialysate, increased risk of infection by failure to maintain the water room in a clean manner and failure to conduct the appropriate cultures.

J. ensure STAT/one time orders for chemical restraints were administered only one time. The facility also failed to ensure the one time order was not written or used as a PRN (as needed) medication, with a possibility of the patient receiving multiple doses of psychotropic medications, that could cause serious harm or potential death in 1 (#54) of 3 (#54-56) charts reviewed.

K. ensure the behavioral unit was free of safety hazards that could be used to cause harm to patients.



Findings:

A. Review of medical record #5 revealed the staff failed to notice the conductivity variance was greater than 0.3mS/cm between the dialysis machine and the handheld meter. The FMC-CS policy # IS-I600-028C2 dated 05-Nov-2013, "3.The conductivity on the dialysis machine must be within 0.3 mS/cm of the reading taken with the handheld conductivity meter or dialysis treatment(s) may NOT be initiated. " (Sic) The staff failed to follow their own policy.

B. Review of medical record #5 revealed the staff failed to compare the conductivity between the machine and the independent device on 05/11/2015. The conductivity of the phoenix meter was the only reading documented.

C.- D. Review of the phoenix meter logs revealed the staff failed to conduct the monthly second level calibration of meters 03773K and P35315 for the month of December 2015. In addition there were no logs for meter P35315 for the months of January and February. In an interview with staff #57 on 05/18/2015 at 2:30 p.m. he confirmed there were no logs for this meter for January and February that indicated if the meter was in service or out of service.

E. Review of the maintenance record for dialysis machines OKOS-162237, OKOS-162328, OKOS-162271 and OKOS-162316 revealed the staff failed to change the dialysate filter every ninety days.

Machine OKOS-162237 dialysate filter was changed in January, April, and July but the staff failed to change the filter in October 2015.

Machine OKOS-162328 dialysate filter was changed in February, May and August but the staff failed to change the filter in November 2015.

Machine OKOS-162271 dialysate filter was changed in January, April, and July but the staff failed to change the filter in October 2015.

Machine OKOS-162316 dialysate filter was changed in February, May and August but the staff failed to change the filter in November 2015.

F. Review of the maintenance and disinfection records revealed the staff failed to collect weekly cultures and endotoxins until they achieved 4 consecutive negative cultures when the membranes were changed on December 20, 2015. Review of the water cultures revealed they did not collect water cultures and endotoxins until the monthly cultures were due on 1/20/2016.

An interview with staff # 57 and 58 on 05/18/2016 at 12:30 p.m. confirmed findings in A-F.

G. Review of employee health files for staff #7, #8, #10, #11, #19, #20, #43, #47, #50, #51, #52, #53, and #54 revealed there was no evidence of Hepatitis B immunizations or evidence of Hepatitis B antibody conversion or non-responder status. An interview with staff # 10 on 05/17/20016 at 3:30 p.m., confirmed the findings in the personnel records.

H. August 2015 through April 2016 Quality Improvement Meeting minutes for the dialysis unit were requested numerous times from staff #'s 6, 10 and 56 on May 16-18, 2016. The minutes of the meetings were never provided. Staff # 56 stated several times she could find the minutes from early 2015 and 2014 but could not find August 2015-April 2016 minute book. Staff # 10 provided 2 tables of data dated March and April 2016 of reporting but there was no evidence the committee reviewed the reports and made recommendations for corrective action if indicated. An interview with staff # 10 confirmed they did not have the minutes for the dialysis Quality Improvement Meetings.

An interview with staff # 10 on 05/18/2016 at 4:30 p.m. confirmed the above findings in G and H.

I. During a tour of the dialysis water room on 05/17/2016 at 10:00 a.m., the water room floor was noted to be dirty with what looked like a black substance over the entire floor. An interview with staff # 58 on 5/17/2016 at 10:00 a.m. confirmed the water room condition.








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J. Review of patient #54 ' s medical record revealed the patient was psychotic and had episodes of aggressive behaviors. Patient #54 was placed on Zyprexa (antipsychotic medication) and Ativan (benzodiazepine) by mouth as part of her medication regimen. Patient #54 had been aggressive and volatile with staff and patients. The physician was called and the nurse wrote the restraint medication order as Zyprexa 10mg IM and Ativan 1 mg IM every 8 hours PRN (as needed) for psychotic agitation on the paper physician orders, a section of the restraint and seclusion form. The nurse then transcribed the order to the computer as written. The computer documentation read the same. However the start date to administer the medication was 5/1/16 at 10:58 and the stop date was 5/1/16 at 11:01 AM. The order was discontinued as a one-time order.
Another order was written for patient #54 on 5/3/16 Zyprexa 10mg IM and Ativan 2 mg IM every 8 hours PRN (as needed) for agitation. The start date was 5/3/16 at 7:15 and stopped at 5/3/16 at 8:18AM. The order was discontinued in the computer as a one-time order but did not match the verbal hand written order as a PRN. There was no orders written to clarify or change the orders to one time dose.

An interview was conducted on 5/17/16 with staff #87(Pharmacist) regarding the medication orders. Staff #87 reported the pharmacist only saw the orders placed in the electronic record. The pharmacist was not aware of the written orders. Staff #87 reported there were no written orders that she was aware of. Staff #87 reported the pharmacy watches the orders for chemical restraints but only what was entered into the computer. Staff #87 could not explain why the PRN order said PRN in the computer and was stopped as a one-time order.

An interview was conducted with staff #88 (RN). Staff #88 showed the surveyor and staff #5, 87, 89, and 91 how the nurse places the written order in the electronic record. Staff #88 reported the nurse would enter the order into the "Order Entry" section of the electronic record. The screen displayed a "frequency" and "priority choice" . However between the "frequency" and "priority" choice was a section "PRN frequency" and the nurse could choose "Once PRN." The error resulted in the medication to appear on the Medication Administration Record (MAR) as a PRN (as needed.) This would allow the staff to read the order to be administered as a " PRN " instead of the one-time dosage. This could cause the patient to possibly receive an overdose of medications and allowed the Nurse to make a decision about a chemical restraint without notifying the physician.
This deficient practice was determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


K. During a tour of the Behavioral Health Unit on 5/16/16 revealed the following;
UNIT 100 Child Unit
1.) In the Therapist Room/Physician Office blinds were across the window on the left side with approximately 3 foot long cords and chain to pull the blinds open and closed. The blinds on the right side of the window were tied with an approximately 15-20 inch plastic cord. The cords and chain can be used as a device for patient harm or as a weapon.
2.) The child playroom had approximately 3 foot long cords and chain hanging from the blinds in reach of patients.
3.) The child group room and main dayroom had an unsecured Television screens with TV and DVD cords hanging down from the back. The TV screens could be broken and used as a weapon. The dangling cords could be used as a device for patient harm or as a weapon.
4.) In the child group room an unsecured cabinet was found. The cabinet had DVD's, paints, art supplies, and games. The art supplies and DVD's could be used to harm themselves.
5.) A large dry erase board in the child playroom was found loose and unsecured from the wall.

UNIT 200 Adolescent Unit-

6.) The adolescent main dayroom had an unsecured Television screen with TV and DVD cords hanging down from the back. The TV screen could be broken and used as a weapon. The dangling cords could be used as a device for patient harm or as a weapon. The blinds on the right side of the window was tied with an approximately 15-20 inch plastic cord. The cords and chain can be used as a device for patient harm or as a weapon.

UNIT 300 Adult Unit-
7.) The main dayroom had an unsecured Television screen with TV and DVD cords hanging down from the back. The TV screen could be broken and used as a weapon. The dangling cords could be used as a device for patient harm or as a weapon.
8.) Blinds in the dayroom had long 15 to 20 inch cords hanging down in patient reach.

UNIT 500 Dual Diagnosis Unit
9.) Blinds in the dayroom had long 15 to 20 inch cords hanging down in patient reach.

Activity Room
13.) Behind the electronic basketball goal a 4-5 ft electrical cord was found unsecured and accessible to patients.
14.) Window blinds had long 15 to 20 inch cords hanging down in patient reach.

Based on observation, interview and record review the facility failed to:


A. ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures. These findings had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure staff were competent. Citing 5 (#11, #12, #13, #21 and #22) of 6 (#11, #12, #13, #14, #21 and #22) personnel records for staff working on the hemodialysis unit.

The facility failed to provide clear lines of authority and responsibility for staffing of the Observation Unit.


Refer to tag A0386


B. ensure that procedures were in place to ensure hospital nursing personnel had a current and valid license. These findings had the likelihood for an unlicensed nurse to obtain employment and care for patients. Citing 3 (#12, #21 and #22) of 3 (#12, #21 and #22) Registered Nurse files reviewed from the hemodialysis unit.


Refer to tag A0394

C. ensure registered nurses provided continuous and accurate evaluation of patients on suicide precautions and patients who were at risk for nutritional complications. This deficient practice was found in 5 of 5 sampled patients (Patient #'s 11, 17, 18, 19, and 20)


Refer to tag A0395


D. administer medication using procedures specified by hospital policy for Enteral Feedings/Medication in 1 patient (Patient #16) of 1 patient observed.

Refer to tag A0405



E. ensure 1 of 1 sampled patients receiving blood transfusions received continuous monitoring (Patient #14).


Refer to tag A0409.

Based on record review and interview the Chief Nursing Officer failed to:

A. ensure all nursing staff had current competencies and were qualified by education to perform invasive procedures. These findings had the likelihood to cause harm to all patients receiving care at the facility by failure to ensure staff were competent. Citing 5 (#11, #12, #13, #21 and #22) of 6 (#11, #12, #13, #14, #21 and #22) personnel records for staff working on the hemodialysis unit.

B. provide clear lines of authority and responsibility for staffing of the Observation Unit.


A. Findings:

Review of the facility policy Competency Assessment #200.141, 3. "Competency will be assessed annually by: a. Performance evaluation. b. Completion of unit specific self-assessment and manager/peer validation. c. Continued licensure, registration or certification. d. Annual fit testing. e. Learner paced modules and post-test, as appropriate. f. Return demonstration."

Review of staff #11's personnel record revealed the competencies were last evaluated in May 2014.

Review of staff #13's personnel record revealed the competencies were last evaluated in May 2014. In addition, staff # 13 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses.

Review of staff #11's personnel record revealed there were no documented competencies in the personnel file. In addition staff #11 was an unlicensed technician and was allowed to cannulate AV Fistulas and AV Grafts; there was no evidence of training by the facility. An interview with staff #10 on 05/17/2016 at 10:30 a.m. confirmed there was no policy approved by the Chief Nursing Officer and Governing Body of the Hospital to allow unlicensed technicians to cannulate accesses. There also was no evidence staff #11 had taken CPR.

Review of staff #21's personnel record revealed the competencies were last evaluated in June of 2013. In addition the CPR expired in February 2016.

Review of staff #22's personnel record revealed the competencies were last evaluated in October 2013. In addition the CPR expired in February 2016.

Interview with staff # 10 on 05/17/2016 at 4:30 p.m. confirmed the above findings.




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B. Findings.

Review of Emergency Department staffing records showed that nurses from the Emergency Department were assigned on a regular basis to staff a unit of the hospital, the Observation Unit, which is not part of the Emergency Department.

An interview with Staff #66 was conducted on the morning of 5-16-2016 in the Emergency Department. Staff #66 stated there was an Observation Unit that had been created for patients whose treatment in the Emergency Department was completed and were admitted to the hospital in Observation Status. The Observation Unit was started November 1, 2015. The Unit is run by another director from the hospital and staffed during the daytime shift with hospital staff.

During the night shift, 7:00 PM to 7:00 AM, the Emergency Department is required to staff the Observation Unit with two nurses. Staff #66 stated she is responsible for the employees on night shift. At night, a minimum of two staff members were provided. Should a problem arise on the night shift, her employees should notify both her and the Observation Unit director, depending on what the problem was. Staff #66 stated that the Observation Unit director had authority over the unit.

Review of the hospital organizational chart showed that the Observation Unit does not appear on the organization chart. Review of Emergency Department Staffing Matrix does not specify dedicated nurse staffing for a hospital Observation Unit.

Based on record review and interview the facility staff failed to ensure that they had a procedure in place to ensure hospital nursing personnel had a current and valid license. These findings had the likelihood for an unlicensed nurse to obtain employment and care for patients. Citing 3 (#12, #21 and #22) of 3 (#12, #21 and #22) Registered Nurse files reviewed from the hemodialysis unit.

Findings:

Review of the Texas Board of Nursing website Texas Nursing Bulletin Volume 39, No 3 dated July 2008 stated "After September 1, 2008 Nurses and employers should go to the agency website at www.bon.state.tx.us and verify licenses on line. The verification, once printed, will resemble a license and will allow the nurse to have the documente laminated for the purpose of carrying the license with them."

Review of nursing personnel records for staff # 12, #21 and #22 the facility had only verified the nurse's licensure status at the Texas State Board of Nursing web site by searching the nurse's name. The site was not searched by either license number or Social Security Number and date of birth, in order to verify that the nurse working was the same licensed nurse found on the board site. When the site was searched for a nurse by name only, a list of nurses with that name is all that is available to the person running the verification. In order to obtain the correct nurse's license, the site must be searched by either the license number or social security and date of birth.

Review of personnel record for staff #12 who worked in the dialysis unit revealed there was a list from the board of nursing web site that contained 6 Registered Nurses by her same name. In addition the licenses were expired for all 6 nurses listed. There was no way to tell which of the nurses was working at the facility.

Review of personnel record for staff #21 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license listed under this name expired in 01/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

Review of personnel record for staff #22 revealed the copy of the board form ran by name only did not contain a license number. The record also indicated the license under this name had expired in 10/31/2013. There was no evidence the facility had searched using the above process in order to be sure this was the correct nurse and the license was current.

An interview with staff #10 on 05/18/2016 at 14:30 p.m. confirmed the above findings.

Based on interview and record review the facility failed to ensure registered nurses provided continuous and accurate evaluation of patients on suicide precautions and patients who were at risk for nutritional complications. This deficient practice was found in 5 of 5 sampled patients (Patient #'s 11, 17, 18, 19, and 20)

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


Review of the clinical record of Patient #11 revealed he was a 42 year old male who presented to the Emergency Department on 05/15/2016 at 10:26 a.m. Patient #11 was classified as being at an Emergent level and was given diagnoses of acute psychosis and polysubstance abuse.
Review of nurses notes revealed documentation that Patient #11 was at risk of injuring himself or others.
According to documentation in the nurses notes at 11:00 a.m. Patient #11 required 1:1 observation.
Review of the clinical record revealed the first documentation of implementation of suicide precautions was at 1:30 p.m. (3 hours after presenting to the ED) on 05/15/2016. According to documentation starting at 10:00 a.m. on 05/16/2016, staff revealed Patient #11 was no longer on suicide precautions.
Staff #68 confirmed the findings in the chart and reported Patient #11 was still on suicide precautions. There was nothing in the chart discontinuing the precautions. Staff #68 reported the nursing staff member should not have changed the precautions on the assessment.
Review of a facility policy named "Suicide Precaution" Code 19-16 revealed the following:
"PROCEDURE
C. Once either level of suicide observation is initiated it will remain in effect until discontinued by the attending physician or the on call physician may discontinue suicide precautions. Document his/her assessment of the patient's current clinical state upon which decision is made must be in the medical record."


Review of the clinical record of Patient #17 revealed she was a 55 year old female who was admitted on 05/11/2016 with a diagnoses which included a diabetic foot infection.
Review of the initial nursing assessment dated 05/11/2016 revealed Patient #17 had no nutritional risk identified.
Review of physician orders revealed Patient #17 was on a Renal dialysis (4 gram sodium/low potassium/low phosphorus) diet.
Review of a dietary assessment by the dietitian dated 05/12/2016 revealed Patient #17 was in stage 4 renal failure and on dialysis. Patient #17 had right foot cellulitis and had a decreased appetite. There was nutritional impairment since hospitalization and prior to admission for several days. The clinical recommendation was as follows:
"PATIENT WITH POOR APPETITE. CONSIDER APPETITE STIMULANT. CONSIDER CHANGING DIET TO DIABETIC, DCING DIALYSIS RESTRICTION, K+IS WNL, NO PO4 LAB ON CHART. OFFERED SUPPLEMENTS, PATIENT REFUSED. THANKS"
During an interview on 05/17/2016 after 1:00 p.m., Staff #80 (dietitian) reported she performed the assessment and made the recommendation on 05/12/2016 (5 days ago). Staff #80 confirmed she could not find a response to her recommendation.


Review of the clinical record on Patient #19 revealed he was a 7 year old male admitted on 05/15/2016 with a diagnosis of facial cellulitis. Patient #19 was receiving intravenous antibiotic therapy while being hospitalized.
Review of the chart revealed no category of the assessment to determine dietary risk which would prompt a dietitian' s assessment.

Review of the clinical record on Patient #20 revealed he was a 10 year old male admitted on 05/13/2016 with diagnoses which included nausea, vomiting, and dehydration. Patient #20 had allergies to bactrim, bananas, strawberries and sulfa.
Review of the chart revealed no category of the nursing assessment to determine dietary risk which would prompt a dietitian's assessment.
Review of the chart revealed no assessment from the dietitian to address dietary needs for this high risk patient.

During an interview on 05/17/2016 after 3:30 p.m., Staff #82 confirmed the missing assessments. Staff #82 reported they did not have the option in their assessment to determine dietary risk like the other nursing units.


36827

Review of the clinical record on Patient #18 revealed he was a 59 year old male transferred from another hospital on 5-13-2016 due to dysphagia related to a recurrent cancerous tumor affecting his ability to swallow and speak. The patient had a Percutaneous Endoscopic Gastrostomy (PEG) tube placed approximately 4 years prior to this admission. A PEG tube is a tube inserted through the skin, into the stomach to provide nutrition when a patient cannot take adequate nutrition by mouth. The patient had been able to take nutrition by mouth up to this point. On 5-14-2016 at 00:19 AM, a nutrition consult was automatically triggered due to the admission nursing assessment identification of difficulty chewing and difficulty swallowing. The patient was on a full liquid diet by mouth.

On 4-14-2016 at 2:12 PM, the physician ordered the nursing staff to start PEG tube feedings at a low rate of 15 cubic centimeters (cc). The physician ordered the patient to be NPO (nothing by mouth). The physician ordered a nutrition consult. The order for a nutrition consult was discontinued as a duplicate.

On 4-16-2016 at 11:48 AM, the physician re-ordered the nutrition consult a second time. The nutrition consult had not been completed by this time. This order was also discontinued.

On 4-16-2016 at 3:09 PM Staff #80 completed a nutritional assessment. Staff #80 assessed that this patient was at high nutritional risk and recommended that the PEG tube feedings be increased to a goal rate of 50 cc per hour.

The policy titled Nutrition Services Assessment (no policy code) was reviewed. It was found to state "Clinical Dietitians will provide Nutritional Support to inpatients at (the hospital) within 96 hours of notification." The policy does not delineate between high risk patients or routine consults.

An interview with Staff #80 was conducted on the afternoon of 5-17-2016. Staff #80 explained that Clinical Dietitians are not in the hospital for dietary consults over the weekend. The original consult was placed on Saturday and not completed until Monday afternoon. This was within the 96 hours specified by the policy. Staff #80 explained that her department has an on-call dietitian to perform assessments for high risk patients when the nursing staff notifies them. Staff #80 stated she had been on call over the weekend in question and that she had not received a call for a consult.

Patient #18 was discharged the day after the nutrition consult was completed. Review of the chart for Patient #18 showed that an order to increase the feeding to a goal rate of 50 cc per hour was never placed by the physician. At discharge on 5-17-2016, Patient #15 was still only receiving nutrition at 15 cc per hour.

Based on observation and review of policy, nursing staff failed to administer medication using procedures specified by hospital policy in 1 (Patient #16) of 1 patient observed.
This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On the morning of 5-17-2016, Staff #72 was observed while administering medication to Patient #16 via the feeding tube. During the process, Staff #72 was observed to stop the feeding, disconnect the feeding tube from the feeding pump, administer the medication into the feeding tube, use water to flush the medication through the feeding tube, reconnect the feeding to the feeding pump, then resume the feedings.

During interview, Staff #72 verbalized the steps she had taken. Staff #72, then provided a copy of the policy titled "Enteral Feeding/Medication, Policy Code 200.063". The section titled "Medication Administration" listed step number 3 as, "Flush tubing before and after medication administration with 20-30 ml's of water." Staff #72 acknowledged that she had missed the step in the procedure requiring her to flush the tubing prior to administering the medication into the tube.

Based on interview and record review the facility failed to ensure 1 of 1 sampled patients receiving blood transfusions received continuous monitoring (Patient #14).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the clinical record of Patient #14 revealed he was a 69 year old male who presented to the Emergency Department on 05/14/2016 at 4:00 a.m.. Patient #14 presented with diagnoses which included gastrointestinal bleed and altered mental status.
Review of lab results at 4:24 a.m. revealed Patient #14 had a low hemoglobin of 7.3 (reference ranges being 14-18) and a hematocrit of 23.7 (reference ranges being 38.0-54.0). Patient #14 had a Partial thromboplastin time (PTT) greater than 500 ( reference ranges being 22.4-37.2). The PTT being a test to check the blood's clotting ability.
A physician order was written at 5:16 a.m. for two units of leuko reduced red blood cells STAT (immediately).
Review of the transfusion records for both units revealed they were signed off by the lab technician at 5:23 a.m. on 05/14/2016.
The following instructions were documented on the transfusion forms:
"Prior to starting this transfusion, an RN and one other licensed personnel have completed all clerical checks including verifying the patient name, account number, and sample number on this slip with the patient's armbands at bedside and all information given."
There were two places for signatures of staff that were not completed.
The pre-transfusion vital signs, 15 minute transfusion vital signs, post-transfusion vital signs, transfusion start time, transfusion stop time, amount transfused and if the patient was observed during transfusions were not completed on the forms.

Review of the record revealed Patient #14 received another unit of blood during a bedside procedure in the intensive care unit on 05/14/2016. According to the transfusion form the blood was started at 6:11 p.m. and stopped at 6:20 p.m.. The pre-transfusion vital signs, 15 minute transfusion vital signs, and post-transfusion vital signs category were left blank. There was documentation on the transfusion record referring you to the anesthesia record. There was a set of vital signs performed before the procedure, but they were not timed. There were vital signs taken during the procedure, but they did not include a temperature.
Staff #83 confirmed the missing documentation.

Based on record review and interview the facility staff failed to ensure the medical record was legible and authenticated with the full name and title of staff. Citing 3 months (February, March and April) of 3 months (February, March and April) of water logs reviewed and 5 (#4, #5, #12, #43 and # 44) of 5 (#4, #5, #12, #43 and # 44) hemodialysis patient medical records reviewed.


Findings:

Review of the facility policy titled "Documentation Charting by Exception Policy code 200.009 p 2", third bullet, "Nursing care is documented and signed by a Registered Nurse or Licensed Vocational Nurse. A signature either electronic or handwritten includes name, full title date and time on all medical records."

Policy titled Medical Records Documentation (No number) "All entries should be dated and timed. All entries must be legible including hand written signatures." Page 2. "If an entry is made in a hand written medical record, the entry, the information may not be obliterated or otherwise altered by blacking out entry with a marker or whiteout, or writing over entry etc." (Sic)

Review of three months of chlorine logs and water logs for February, March and April revealed they both contained numerous write over of times and numbers. Some of the numbers were obliterated. An interview with staff # 58 on 05/17/2016 at 11:30 a.m. confirmed the findings in the logs.

Review of the Dialysis Patients #4, #5, #12, #43 and # 44 handwritten treatment notes revealed there was no evidence of the time or who conducted the pre-dialysis assessment. There was no evidence that the assessment was even conducted by a Registered Nurse (RN). In addition there was no way to tell who documented on each entry in the records including who gave the medication or packed red blood cell transfusions. The timed entry did not contain a person's initials that was legible. The staff failed to legibly sign their full name, time and title after each entry as required by policy.

An interview with staff # 10 on 05/18/2016 at 2:30 p.m. confirmed the above findings in the hemodialysis medical records.

Based on record review and interview, the Physician failed to complete the date and time on the History and Physical update record prior to surgical procedure on 1 of 6 surgical charts reviewed.
A review of surgical chart #45 History and Physical update record revealed that Physician #49 failed to date and time when the update to the History and Physical record was completed. There was no way to determine if the History and Physical update was performed prior to the surgical procedure.
An interview with Staff #23 and #24 on 05/18/2016 at 11:30 AM confirmed the above findings.

Based on observation, document review and interview, the facility failed to:
1. ensure the Pharmacy Department was appropriately cleaned and damaged equipment/supplies, that could not be adequately cleaned, were reported and replaced to prevent the transfer of potential bacteria.
A tour of the facility's Pharmacy Department on 5/16/2016, revealed the following observations:
· One heavy duty metal tape dispenser was observed in the ante room used to prepare supplies and medications to be transferred and used in the adjacent sterile IV (intravenous) preparation room. Upon examination of the tape dispenser, the surveyor observed multiple areas of chipped paint, rust, dust and debris on all sides of the dispenser.
· Two heavy duty metal tape dispensers were observed in the main pharmacy area on top of a metal counter being used to prepare packaged medications for distribution to the patient units throughout the facility. Upon examination of the two tape dispensers, the surveyor observed multiple areas of chipped paint, rust, dirt and debris on all sides of the dispensers.
· Two silver metal storage trays were observed in the main pharmacy area on top of a metal counter being used to prepare packaged medications for distribution to the patient units throughout the facility. The storage trays were being used to hold medications prepared for patient distribution and expired medications. Upon examination of the two storage trays, the surveyor observed multiple damaged areas, dirt and debris on all outer sides, bottom and inside of the trays.
A review of the facility's policy titled, "Cleaning of Non-Critical Equipment" revealed the following statement:
" ...GENERAL PRINCIPLES FOR INFECTION CONTROL ....
3. Any damaged equipment must be reported to the department manager for decision
regarding replacement or the ability to clean."
An interview conducted on 4/16/2016, with the Director of Pharmacy, staff #33, confirmed the above findings.


2. ensure employees followed infection control standards when packaging unit dose medications.
A tour of the facility's Pharmacy Department on 5/16/2016, revealed the following observation:
An interview was conducted on 5/16/2016, with the Pharmacy Director, staff #33. During the interview, the surveyor observed a pharmacy employee using a machine to package oral medication into separate unit dose sealed packages. The machine processed multiple individually sealed packages in a long strip with perforations for separating each package. The employee was holding the strip that was approximately 6 to 8 feet long over the pharmacy room floor and separating each package along the perforated lines while the opposite end of the strip was dragging on the floor. The observation was pointed out to the Pharmacy Director, staff #33, who agreed with the findings.

Based on observation, interview, and review of record the facility failed to:

A. have adequate emergency supplies available and organized in a manner that it was ready for use in an emergency situation in 2 out of 2 departments (2WB Intensive Care Unit (ICU) and Emergency Department). This deficient practice could place all patients experiencing an emergent condition at risk of harm.

B. remove specimen collection tubes from use prior to their expiration date in 2 units (2WB ICU and Oncology Unit) out of four units observed (Emergency Department, 2WB ICU, Oncology Unit, and Pediatric Unit). This deficient practice could place all patients at risk of harm.

C. tag equipment with Programmed Maintenance (PM) dates and remove equipment from service when the PM is overdue in 2 units (Emergency Department and Oncology Unit) out of four units observed (Emergency Department, 2WB ICU, Oncology Unit, and Pediatric Unit). This practice leaves potentially unserviceable equipment to be used on patients.

Findings:

A. An inspection of the Pediatric Crash Cart was completed in the Emergency Department on 5-16-16 with Staff #66 and Staff # 68. The Crash Cart was sealed and ready for use. Upon examination of crash cart records and inventory, it was found the following items were below PAR levels (minimum level) in the drawer location specified for the cart:
Purple Drawer:
1) 4.0 Hi/Low (a breathing tube used to provide emergency airway to patients) - Par 2 - Only one found
2) 6 French Stylet (Pedi) (an instrument to assist in placing an emergency breathing tube) - Par 4 - Only 2 found
3) CO2 Detectors (Pedi) (an instrument to check for proper placement of a breathing tube) - Par 2 - None found
4) Bulb Syringe (an instrument used to clear the nasal and oral airways) - Par 1 - None found
5) Urinary Caths 6 French Silicone (an instrument used to drain or irrigate the bladder) - Par 1 - None found
Red Drawer
6) 3.0 Hi/Low - Par 1 - None found
7) 6 French Stylet (Pedi) - Par 4 - Only 3 found
8) CO2 Detectors (Pedi) - Par 2 - Only 1 found
9) Chest Tube 12 French (a tube inserted into the chest cavity in emergencies to drain fluids and/or expand a collapsed lung) - Par level not identified on sheet - None found

In addition to missing equipment, additional equipment items were found in the drawers that were not listed on the inventory. Equipment was not organized and made it very difficult for Staff #68 to find items as they were being called out.

The Pediatric Crash Cart had a posting "Do Not Remove Oxygen Tank". The oxygen tank had been removed from the cart.

During interview Staff #68 stated that equipment was not needed in the quantities specified by the established Par Levels so they hadn't been stocked as high. Staff #68 was not able to produce documentation of newly established Par Levels or updated inventories.

An inspection of the Adult Crash Cart was completed in the 2WB ICU on 5-16-16 with Staff #73 The Crash Cart was sealed and ready for use. Upon examination it was found that the only items listed with locations and Par Levels were emergency medications. The first two drawers contained well organized medications to include picture layout charts of where to find the medications in an emergency. Vasopressin (a medication previously used for emergency cardiac events) was still listed on the inventory. It had been removed from the cart permanently. Staff #73 stated the inventory just hadn't been updated and everyone was aware that Vasopressin was no longer a part of the algorithm (procedures) during Code 44s (emergency situations).

The second drawer and remaining drawers/shelf contained a variety of supplies and equipment. There was no inventory or established Par Levels. This made it impossible to know what was available on the cart during an emergency. A sterilized wrapped pair of hinged instruments was on the cart. The instruments had been sterilized in the closed position, preventing all surfaces from being properly sterilized. The equipment and supplies were not organized with like supplies together. Staff #73 stated that he was not aware of an inventory and the Crash Cart was stocked with items they may need in Code 44.

B. On the morning of 5-17-2016, a tour of the 2WB ICU was conducted with Staff #73 and Staff #83. The following expired tubes for collecting specimens from patients for laboratory analysis were observed in the supply room for use by staff:

1. BD BBL Vacutainer Anaerobic Specimen Collector expired on 2015-10 (October 2015).

2. BD BBL Vacutainer Anaerobic Specimen Collector expired on 2016-03 (March 2016).

3. BBL Culture Swab expired on 2016-04 (April 2016).

Staff #73 and Staff #83 acknowledged that these supplies were out of date and had not been removed from service.

On the afternoon of 5-17-2016, a tour of the Oncology Unit was conducted with Staff #76. The following expired tube for collecting specimens from patients for laboratory analysis was observed in the supply room for use by staff:

1. BD BBL Vacutainer Anaerobic Specimen Collector expired on 2014-08 (August 2014).

Staff #76 acknowledged that the collection tube was out of date and had not been removed from service.

C. On the morning of 5-16-2016, a tour of the Emergency Department was conducted with Staff #66. A portable Ultrasound Machine was found in the room designated as Trauma 1. The equipment did not have a PM sticker on it to identify when the next inspection/maintenance was due. Staff #66 contacted the Biomedical Services department responsible for maintaining the equipment. Records were provided by the Biomedical Services Department to show the equipment had been recieved and inspected in Febrary 2016 and was not due maintenance at this time.

On the afternoon of 5-17-2016, a tour of the Oncology Unit was conducted with Staff #76. A room was designated for the storage of equipment that was serviceable and ready for use. A portable Ultrasound Machine was found in the equipment storage room, ready for use. The equipment did not have a PM sticker on it to identify when the next inspection/maintenance was due. In addition, the following two N-600x Pulse Oximeters (equipment used to continuously monitor a patient's oxygen levels) were found to be past their PM Due dates:

1. Biomedical Services #42676 PM Due 9-15 (September 2015)
2. Biomedical Services #42661 PM Due 2-16 (February 2016)

On the afternoon of 5-17-2016 an interview was conducted with Staff #78 and Staff #79. Staff #78 explained that there was no requirement to put PM Due stickers on equipment. Staff #79 stated that if the two portable Ultrasound Machines were on the units, they had been inspected and were ready for use. This contradicted the finding of two other pieces of portable equipment that were on the units and ready for use despite being past their PM date. Staff on the floor had no immediate way of knowing if equipment was due or overdue PM without the PM Due stickers. No further explanation was provided by Staff #78.

Based on observation, interview and record review the facility failed to ensure there was a sanitary environment in 7 of 7 patient care areas ( Emergency Department, Oncology Unit, Pediatrics Unit, Intensive Care Unit, Sleep Center, Behavioral Health Unit, and Off-Site Emergency Department).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

During an observation on 05/16/2016 after 10:30 a.m. the following was found:

EMERGENCY ROOM
*A treatment cart was stored in the hallway and contained medical supplies. The plastic containers which held the medical supplies were soiled with a build-up of dry spills, debris and dust.
* Exam room #2 and Exam #3 had mattresses which had tears exposing the inner contents. Both mattresses could not be sanitized. Both bed frames were soiled with a build-up of dirt, dust and old tape. The bed frame in Exam room #3 was soiled with a dried red substance (with the appearance of blood).
*The mop, mop bucket and housekeeping cart were stored in the hallway next to the medical supply cabinets and the Pyxis medication machine. There was no separation of clean and dirty.
*The inside of the medical supply cabinet had a build-up of dust and dried spills inside the drawers. The walls in the cabinet were soiled with dry spills.
*Patient styrofoam cups that were not bagged were stored in a drawer that had dust in it.
*Bottles of peroxide and wound packing gauze were stored in a drawer that had debris. Open unbagged gauze was stored in drawers which were soiled. Some of the gauze was soiled with debris.
*An unbagged unsterile piece of equipment was stored in a drawer with peel packets of sterile equipment. There was no separation of sterile and unsterile.
*Peel packets of hinged equipment was stored in a supply cabinet and ready for use. The hinges were in a locked position which made it impossible to ensure the equipment was sterile.

According to the Association of Perioperative Registered Nurses, page 548, edition 2014 the following was recommended:

"Recommendation XII: Cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces.
XII.c. Instruments with hinges should be opened and those with removable parts should be disassembled when placed in trays designed for sterilization, unless the manufacturer had provided validated instructions to the contrary.
Sterilization occurs only on surfaces that have direct contact with the sterilant. Disassembly of multiple-part instruments and those with sliding parts (e.g. Retractors) enables the sterilant to contact all surfaces.
XII.c.1. Instruments should be kept in the open unlocked position using instrument stringer, racks or instrument pegs designed to contain instruments."


*Psych room- The bottom covering of the bed mattress was wet creating a medium for bacteria growth. The bed frame in the room had a build-up of dust and dried spills. There was a dried brown substance on the frame which had the appearance of feces. The base boards were soiled with dirt, debris and the wall in the room had peeling plaster.
*A clean linen cart in the hallway had splash guards which were soiled with a buildup of a brown substance.
*Shipping boxes were found on shelves in the pharmacy.
According to the Association for the Advancement of Medical Instrumentation ST46-Section 5.2 Receiving Items the following was documented:
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items)"

*A clean supply room was found with splash guards on the shelves which were too short. They did not provide full protection for all supplies on the bottom shelves.

*Inside the trauma room a pair of soiled scissors were found stored in a drawer with casting supplies.
The base of the ultrasound equipment was soiled with a build-up of dust and dried spills.
Peel packets of sterile equipment was stored in a drawer which was soiled with spills.
Medical supplies were stored in the bottom cabinet on the crash cart and it was soiled with a build-up of dust and debris.
The bed mattress in the trauma room had tears and could not be sanitized. The bed frame was soiled with dried spills and rusted. There was no way the frame could be sanitized with the rust on it.
Soiled supplies were in the trash and biohazard container inside the trauma room.
Staff #66 and 68 confirmed the observations. Staff #68 reported the room was designated as being clean and the last time it was used was on the day prior (05/15/16) at 12 noon.


ONCOLOGY

Inside the medication rooms were plastic medication bins which had dried spills. Patient medications were stored inside the soiled bins.
Medication crushers in both medication rooms on the unit were soiled with a buildup of dust and debris.
A specimen collector was found stored on the shelf and expired 08/2014.

Staff #76 confirmed the observations.





36827

2WB INTENSIVE CARE UNIT

Inside the clean equipment storage room a portable Ultrasound Machine and equipment poles were found to have dirt, debris, and dried spills on the base of equipment.

The drawers used to hold spare equipment cables and supplies had dust and debris collected in the hand pull at the top lip of the drawers.

Plastic bins used to store supplies were dusty and had debris in them.

A utility cart used for stocking supplies was found to have dust, debris and dried spill on the shelves.

Supply room bottom wire storage shelf did not have a splash guard to prevent floor cleaning chemical from splashing onto supplies.

Clean supplies of patient water pitchers and urinals were stored in bins with pink dried matter in the bottom of them.

Hill-Rom (bed manufacturer) foot board for bed visibly soiled and stored on floor of clean equipment room.

Peel packets of hinged equipment was stored in an emergency cart and ready for use. The hinges were in a locked position which made it impossible to ensure the equipment was sterile.

A pill crusher was found to be visibly soiled with powder residue and dried matter.

Staff #73 and Staff #83 confirmed these observations.


PEDIATRICS UNIT

Room 2203 was cleaned and ready for a patient. It contained an equipment pole with rust at the base and by the rolling caster wheels as well as dried spills. The mattress was visibly soiled with dried matter. The bathroom sink was without caulking where it met the wall. This made it impossible to clean and sanitize properly.


Room 2202 was cleaned and ready for a patient. There was a greenish brown glob of matter hanging from the ceiling tile over the baby crib.

Storage room floor was covered in dust, hair and debris. The wall was visibly soiled.

Wooden hand rails located in the hallway were attached to the wall with wooden blocks that were unsealed and absorbent. Porous materials such as unsealed wood cannot be sanitized properly.

There was an infant weighing scale in the clean equipment room. On the bottom shelf was a foam support cushion that was missing one side of the plastic cover, making it impossible to sanitize between uses. The cart also contained disposable diapers that had previous patients' names and room numbers on them. Staff #82 verified that these had been in patients rooms for use. After patients discharge, unused diapers from the patient's room were stored for use by other patients. This presented the potential for infection to be spread between patients. The floor of the clean equipment room had dust, debris and what appeared to be a pair of used gloves on the floor.

The clean linen storage closet was found to have clean linens under the bottom shelf, on the floor, along with trash. Red duct tape was placed in a horizontal line at the top of the clean linen storage closet to indicate the maximum height for stacking linens. The duct tape was wrinkled, gapped where it was placed over shelf brackets, and the sticky tape residue along the edges collected fibers and dust. This made it impossible to clean properly.

In a separate storage room near the elevators by pediatrics, office supplies were stored with patient equipment. Some patient equipment was wrapped in plastic indicating it was clean and ready to use. Some equipment was not wrapped and could not be determined if it was clean or soiled. The carpeted floor had debris on it. The doorway and threshold had a buildup of dirt. Equipment poles had castor wheels that were caked in rust and visibly soiled at the base. Hand cleaner was being stored on top of plastic bins used to store craft supplies. The back wall had visible streaks of brown dried liquid from the ceiling tiles down to the floor next to a baby crib and an evacuation device for transporting patients.

Staff #6, Staff #10 and Staff #82 verified these findings.



28659

SLEEP CENTER

On 5/18/2016 at 9:30 A.M. observation of the Sleep Center in the patient waiting area the metal mini blinds were broken and bent on the edges. The mini blinds were also observed to be dusty. When two fingers were wiped across the blinds it left a visible track on the blinds and a dark residue on the fingers.

The above was confirmed by staff #61.


OFF-SITE EMERGENCY

On 5/18/2016 at 10:45 A.M. at the South Broadway Emergency Department. Observation of the shared patient waiting area identified 8 of 10 vinyl chair seats with cracks in the vinyl. Cracks in the vinyl would make the chairs impossible to sanitize.

In the trauma room the top drawer of a rolling cabinet was opened and surgical instruments were observed placed in a tray. The instruments were not contained in a sterile paper peel pouch and could not be identified as clean or dirty.

Staff #62 removed the instruments. He confirmed the surgical instruments were no longer in use and didn't know why they were still in the cabinet.









32143

During a tour on the behavioral health unit the following infection control issues were found;

UNIT 100 Child Unit
1.) In the Therapist Room/Physician Office a stack of new patient supplies were found in shipping boxes on a shelf.
2.) In the child group room large blue play pads were found sitting on the floor soiled with dirt, dust, and hair. The pads had holes exposing the inner contents of the pads.
3.) Nine floor tiles in the child playroom were broken or chipped. Broken and chipped tiles are difficult to clean. Dirt and bacteria can harbor in the cracks of the tile.
4.) The Formica on the nurse's station was broken and missing in several places, exposing porous wooden surfaces that are difficult to clean and harbor bacteria.
5.) A large blue and gray vinyl gymnastic mat was found on the child unit torn and soiled with dirt, dust and hair.
6.) In the child playroom blue and red mats were found on the floor soiled with dirt, dust, debris, and hair.
When a patient is discharged from the facility the room must be cleaned for the next patient. The term used for a clean patient room is a "Terminally Clean Room." Terminal cleaning is a cleaning method used in healthcare environments to control the spread of infections.
7.) Room 102 was designated as a "Terminally Clean Room" on the child unit. The room was found to have a soiled windowsill with dust and dead bugs. The facing on the bottom of the window was loose and pealing back. Patient sticker residue was around the window. The bottom of the mattress on bed "B" was soiled on the bottom and had three small holes starting on the mattress.

UNIT 200 Adolescent Unit-
8.) Patient room 204 was a terminally clean room. Room 102 had dead black winged bugs on the bed spread. The top sheet had old tape residue on the clean sheets.
9.) The Formica on the nurse's station was broken and missing in several places, exposing wooden pores surfaces, that are difficult to clean and harbor bacteria.
10.) The medication room had multiple shipping boxes mixed in with patient supplies.

SECLUSION/ RESTRAINT ROOM
11.) Three restraint stretchers were found in the restraint rooms soiled with dirt, dust, and hair. The floors and thresholds were soiled with a buildup of dirt and dust. Paint was missing on the door frames to the seclusion rooms.
12.) The bathroom next to the seclusion room was soiled with dust and dirt on floor, toilet, and shower floor. The metal paper towel and toilet paper holders were rusted. The electrical plug was cracked and broken.

UNIT 300 Adult Unit-
13.) Patient room 310 was a terminally cleaned room. The bed spreads and sheets were soiled with stains, dead bugs, and hairs. The sheets on both the beds had old tape residue on the sheets.
14.) The medication room had a medication refrigerator sitting on the floor. The floor was dusty and dirty. Each time the refrigerator door opened and closed dirt and dust came into the refrigerator. Multiple shipping boxes were found stored in the medication room.
15.) The crash cart was soiled with dust, dirt, and debris.

UNIT 500 Dual Diagnosis Unit
16.) The medication room floor was soiled with dust, dirt, and hair. The cabinets and thresholds were chipped and missing paint.

Based on observation, interview and record review the facility failed to implement policies to control infections. The facility failed to ensure patients with contagious infections and who had a recent history of contagious infections were placed in contact isolation timely. This deficient practice was found in 2 of 2 sampled patients (Patient #'s 13 and 14).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

During an observation on 05/17/2016 after 10:00 a.m., four patients out of a 16 bed unit were noted to be in isolation.

Review of the clinical record of Patient #14 revealed he was a 69 year old male who presented to the Emergency Department on 05/14/2016 at 4:00 a.m.. Patient #14 presented with diagnoses which included gastrointestinal bleed and altered mental status.
Review of the record revealed Patient #14 had a blood culture drawn on 05/14/2016. According to the documentation on the lab sheet dated 05/16/2016 at 12:30 p.m., Staff #85 was informed that Patient #14 was positive for VRE (Vancomycin Resistant Enterococus).

Review of physician orders revealed Staff #85 wrote an order for an isolation cart for contact isolation on 05/17/2016 at 8:15 a.m. (over 19 hours later).
During an interview on 05/17/2016 after 11:30 a.m., Staff #85 confirmed the lab was reported to her on 05/16/2016 and that Patient #14 had just been put in isolation today (05/17/16). Patient #14 should have been placed in isolation on 05/16/2016.



Review of the clinical record of Patient #13 revealed she was a 43 year old female who was admitted to the unit on 05/16/2016. Patient #13 presented with diagnoses which included sepsis with a urinary source, hypotension and chronic renal failure.
Review of the initial nursing assessment dated 05/16/2016 revealed Patient #13 had a recent history of Clostridium difficile and VRE.
Review of physician orders revealed an order was written on 05/17/2016 at 7:26 a.m. for strict contact isolation for a history or C-diff and VRE.
During an interview on 05/17/2016 after 11:30 a.m., Staff #83 confirmed Patient #13 got to the unit at 11:23 p.m. on 05/16/2016 and the history was documented on admission to the unit. Staff #83 confirmed Patient #13 was placed in isolation this morning (05/17/2016).

Review of a facility policy named "Patient Isolation Policy" dated January 1997 revealed the following:
"1. CONTACT PRECAUTIONS
ii. Applies to patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact-e.g.. MultiDrug Resistant Organisms (MDRO's) and Clostridium difficile (C.diff.) as described in Appendix A."
According to Appendix A the following was documented:
C.difficile -contact isolation for the duration of the illness.
MDROs- infection or colonization- strict contact isolation.

Based on observation, record review, and interview, the facility failed to:


A. ensure that surgical technologists working in the surgical department were certified to ensure the health and safety of the surgical patients that were receiving surgical procedures at the facility. Also, the facility violated the Health and Safety Code for Surgical Technologists. The facility, in accordance with the State law and acceptable standards of practice, must establish the qualifications required for who performs the duties as a surgical technologist. A review of 2 (#47 and #48) of 3 surgical technician personnel files revealed the following:

A review of personnel #47 ' s file on 5/17/16 revealed that Staff #47 was hired on 1/27/16 and was currently working at the facility as a surgical technologist. While Staff #47 had worked at the facility previously until 05/2014 the personnel record revealed there was no current documentation that Staff #47 was certified as a surgical technologist. The only signed job description for Staff #47 was an "OR Tech/LVN ".

A review of personnel #48's file on 05/17/2016 revealed that Staff #48 had applied to work at the facility on 02/03/2016 and was currently employed at the facility as an uncertified surgical technologist. A review of the application document revealed Staff #48 had not worked as a surgical technologist since 08/2013 and that surgical technologist certification had expired 05/21/2014. The only signed job description for Staff #48 was an "OR Tech/LVN".

Staff #47 and #48 were not Licensed Vocational Nurses even though they signed the job description titled "OR Tech/LVN".

A review of the facility's job description revealed the job description was for an "OR Tech/LVN" and was last revised 11/2007. The job description had not been updated to address the current rules of the Health and Safety Code for the Surgical Technologist. A job description for surgical technologist was requested numerous times from the facility's Human Resource department, but none were provided.

A review of the Health and Safety Code titled, "TITLE 4. HEALTH FACILITIES SUBTITLE B. LICENSING OF HEALTH FACILITIES CHAPTER 259. SURGICAL TECHNOLOGISTS
AT HEALTH CARE FACILITIES" revealed the following:

"Sec. 259.002. REQUIREMENTS FOR PRACTICING SURGICAL TECHNOLOGY. (a) A health care facility licensed by the department under this subtitle or owned or operated by the state may not employ a person to practice surgical technology in that health care facility unless that person provides evidence that the person:
(1) has successfully completed an accredited educational program for surgical technologists and holds and maintains certification as a surgical technologist by:
(A) the National Board of Surgical Technology and Surgical Assisting or its successor;
(B) the National Center for Competency Testing or its successor; or
(C) another surgical technologist certification program approved by the department;
(2) has completed an appropriate training program for surgical technology in the army, navy, air force, marine corps, or coast guard of the United States or in the United States Public Health Service;
(3) was employed to practice surgical technology in a health care facility before September 1, 2009; or
(4) is in the service of the federal government, to the extent the person is performing duties related to that service.
(b) Notwithstanding Subsection (a), a health care facility may employ a person to practice surgical technology at that health care facility from the date the person graduates from an accredited educational program for surgical technologists until the 180th day after the date of graduation. The person may not continue to practice surgical technology after the 180th day after the date of graduation without showing documentation to the health care facility that the person holds and maintains the surgical technologist certification required by Subsection (a)(1).
(c) Notwithstanding Subsection (a), a health care facility may employ a surgical technologist who does not meet the requirements of this section if:
(1) after a diligent and thorough effort has been made, the health care facility is unable to employ a sufficient number of qualified surgical technologists who meet the requirements of this section; and
(2) the health care facility makes a written record of its efforts under Subdivision (1) and retains the record at the health care facility.

Added by Acts 2009, 81st Leg., R.S., Ch. 321 (H.B. 643), Sec. 1, eff. September 1, 2009."


An interview with Staff #23 and #60 on 05/17/2016 at 3:00 PM confirmed the above findings.


B. monitor humidity and temperature in the surgical department where surgical procedures were performed and sterile instruments were stored. Also, the facility failed to follow their own policy for monitoring humidity and temperature. A review of the records titled, "Temperature Log" from January thru April 2016 revealed the temperature and humidity were out of the normal range. Normal range for temperature was 60-65 degrees and normal range for humidity was 30-60 percent per the temperature log.

Month of January 2016, Unit: Assembly

The temperatures recorded were all above the normal range (normal range was 60-65 degrees). There were 30 days documented above the normal range and one day was left blank.

01/01/2016- 78 degrees
01/02/2016- 74 degrees
01/03/2016- 74 degrees
01/04/2016- 74 degrees
01/05/2016- 74 degrees
01/06/2016- 76 degrees
01/07/2016- 74 degrees
01/08/2016- 75 degrees
01/09/2016- 66 degrees
01/10/2016- 72 degrees
01/11/2016- 76 degrees
01/12/2016- 74 degrees
01/13/2016- 76 degrees
01/14/2016- 76 degrees
01/15/2016- 77 degrees
01/16/2016- 68 degrees
01/17/2016- 68 degrees
01/18/2016- 74 degrees
01/19/2016- 75 degrees
01/20/2016- 75 degrees
01/21/2016- 77 degrees
01/22/2016- 77 degrees
01/23/2016- 73 degrees
01/24/2016- 69 degrees
01/25/2016- Left Blank
01/26/2016- 68 degrees
01/27/2016- 74 degrees
01/28/2016- 74 degrees
01/29/2016- 74 degrees
01/30/2016- 68 degrees
01/31/2016- 68 degrees

Month of February 2016, Unit: Assembly

The temperatures recorded were all above the normal range (normal range was 60-65 degrees). There were 31 days documented above the normal range and February only had 29 days in the year 2016.

02/01/2016- 75 degrees
02/02/2016- 76 degrees
02/03/2016- 74 degrees
02/04/2016- 79 degrees
02/05/2016- 79 degrees
02/06/2016- 67 degrees
02/07/2016- 76 degrees
02/08/2016- 79 degrees
02/09/2016- 78 degrees
02/10/2016- 75 degrees
02/11/2016- 70 degrees
02/12/2016- 75 degrees
02/13/2016- 75 degrees
02/14/2016- 74 degrees
02/15/2016- 74 degrees
02/16/2016- 76 degrees
02/17/2016- 75 degrees
02/18/2016- 78 degrees
02/19/2016- 79 degrees
02/20/2016- 74 degrees
02/21/2016- 74 degrees
02/22/2016- 77 degrees
02/23/2016- 67 degrees
02/24/2016- 76 degrees
02/25/2016- 75 degrees
02/26/2016- 77 degrees
02/27/2016- 76 degrees
02/28/2016- 77 degrees
02 /29/2016-77 degrees
02/30/2016- 76 degrees (extra day documented when the date does not exist)
02/31/2016- 77 degrees (extra day documented when the date does not exist)



Month of March 2016, Unit: Assembly

The temperatures recorded were above the normal range (normal range was 60-65 degrees). There were 30 days documented above the normal range, with one day being within the normal range.


03/01/2016- 78 degrees
03/02/2016- 77 degrees
03/03/2016- 77 degrees
03/04/2016- 77 degrees
03/05/2016- 78 degrees
03/06/2016- 64 degrees * only normal reading for the month
03/07/2016- 80 degrees
03/08/2016- 75 degrees
03/09/2016- 66 degrees
03/10/2016- 68 degrees
03/11/2016- 67 degrees
03/12/2016- 66 degrees
03/13/2016- 71 degrees
03/14/2016- 74 degrees
03/15/2016- 78 degrees
03/16/2016- 74 degrees
03/17/2016- 74 degrees
03/18/2016- 76 degrees
03/19/2016- 76 degrees
03/20/2016- 74 degrees
03/21/2016- 71 degrees
03/22/2016- 75 degrees
03/23/2016- 76 degrees
03/24/2016- 76 degrees
03/25/2016- 75 degrees
03/26/2016- 77 degrees
03/27/2016- 70 degrees
03/28/2016- 77 degrees
03 /29/2016-75 degrees
03/30/2016- 75 degrees
03/31/2016- 80 degrees

Month of April 2016, Unit: Assembly

The temperatures recorded were all above the normal range (normal range was 60-65 degrees). There were 30 days documented above the normal range.

04/01/2016- 73 degrees
04/02/2016- 77 degrees
04/03/2016- 77 degrees
04/04/2016- 73 degrees
04/05/2016- 79 degrees
04/06/2016- 79 degrees
04/07/2016- 74 degrees
04/08/2016- 79 degrees
04/09/2016- 76 degrees
04/10/2016- 70 degrees
04/11/2016- 78 degrees
04/12/2016- 78 degrees
04/13/2016- 78 degrees
04/14/2016- 79 degrees
04/15/2016- 78 degrees
04/16/2016- 73 degrees
04/17/2016- 74 degrees
04/18/2016- 75 degrees
04/19/2016- 75 degrees
04/20/2016- 77 degrees
04/21/2016- 77 degrees
04/22/2016- 77 degrees
04/23/2016- 66 degrees
04/24/2016- 66 degrees
04/25/2016- 79 degrees
04/26/2016- 76 degrees
04/27/2016- 76 degrees
04/28/2016- 78 degrees
04 /29/2016-70 degrees
04/30/2016- 76 degrees

Month of January 2016, Unit: Assembly

The humidity recorded were below the normal range (normal range was 30-60 percent). There were 15 days documented below the normal range. (*- signifies below normal readings)

01/01/2016- 32 %
01/02/2016- 28 %
01/03/2016- 28 % *
01/04/2016- 28 % *
01/05/2016- 31 %
01/06/2016- 28 % *
01/07/2016- 29 % *
01/08/2016- 30 %
01/09/2016- 24 % *
01/10/2016- 30 %
01/11/2016- 31 %
01/12/2016- 29 % *
01/13/2016- 31 %
01/14/2016- 31 %
01/15/2016- 30 %
01/16/2016- 27 % *
01/17/2016- 27 % *
01/18/2016- 30 %
01/19/2016- 31 %
01/20/2016- 30 %
01/21/2016- 32 %
01/22/2016- 32 %
01/23/2016- 30 %
01/24/2016- 28 % *
01/25/2016- 28 % *
01/26/2016- 27 % *
01/27/2016- 30 %
01/28/2016- 30 %
01/29/2016- 28 % *
01/30/2016- 26 % *
01/31/2016- 26 % *


Month of February 2016, Unit: Assembly

The humidity recorded were below the normal range (normal range was 30-60 percent). There were 5 days documented below the normal range and February only had 29 days in the year 2016. (*- signifies below normal readings)


02/01/2016- 30 %
02/02/2016- 30 %
02/03/2016- 31 %
02/04/2016- 32 %
02/05/2016- 32 %
02/06/2016- 22 % *
02/07/2016- 32 %
02/08/2016- 32 %
02/09/2016- 31 %
02/10/2016- 30 %
02/11/2016- 28 % *
02/12/2016- 30 %
02/13/2016- 30 %
02/14/2016- 29 % *
02/15/2016- 29 % *
02/16/2016- 31 %
02/17/2016- 30 %
02/18/2016- 31 %
02/19/2016- 33 %
02/20/2016- 31 %
02/21/2016- 31 %
02/22/2016- 32 %
02/23/2016- 23 % *
02/24/2016- 32 %
02/25/2016- 30 %
02/26/2016- 30 %
02/27/2016- 30 %
02/28/2016- 32 %
02/29/2016- 30 %
02/30/2016- 30 % (extra day documented when the date does not exist)
02/31/2016- 30 % (extra day documented when the date does not exist)

Month of March 2016, Unit: Assembly

The humidity recorded were below the normal range (normal range was 30-60 percent). There were 8 days documented below the normal range. (*- signifies below normal readings)

03/01/2016- 31 %
03/02/2016- 30 %
03/03/2016- 30 %
03/04/2016- 30 %
03/05/2016- 32 %
03/06/2016- 24 % *
03/07/2016- 33 %
03/08/2016- 31 %
03/09/2016- 24 % *
03/10/2016- 30 %
03/11/2016- 25 % *
03/12/2016- 29 % *
03/13/2016- 29 % *
03/14/2016- 29 % *
03/15/2016- 31 %
03/16/2016- 30 %
03/17/2016- 30 %
03/18/2016- 31 %
03/19/2016- 31 %
03/20/2016- 28 % *
03/21/2016- 30 %
03/22/2016- 30 %
03/23/2016- 31 %
03/24/2016- 31 %
03/25/2016- 31 %
03/26/2016- 28 % *
03/27/2016- 32 %
03/28/2016- 31 %
03/29/2016- 30 %
03/30/2016- 30 %
03/31/2016- 32 %


Month of April 2016, Unit: Assembly

The humidity recorded were below the normal range (normal range was 30-60 percent). There were 7 days documented below the normal range. (*- signifies below normal readings)

04/01/2016- 28 % *
04/02/2016- 32 %
04/03/2016- 32 %
04/04/2016- 29 % *
04/05/2016- 32 %
04/06/2016- 32 %
04/07/2016- 29 % *
04/08/2016- 32 %
04/09/2016- 30 %
04/10/2016- 27 % *
04/11/2016- 31 %
04/12/2016- 30 %
04/13/2016- 30 %
04/14/2016- 30 %
04/15/2016- 30 %
04/16/2016- 30 %
04/17/2016- 29 % *
04/18/2016- 30 %
04/19/2016- 30 %
04/20/2016- 30 %
04/21/2016- 30 %
04/22/2016- 30 %
04/23/2016- 23 % *
04/24/2016- 23 % *
04/25/2016- 30 %
04/26/2016- 30 %
04/27/2016- 30 %
04/28/2016- 30 %
04/29/2016- 30 %
04/30/2016- 30 %

A review of the temperature logs revealed no documentation that the variance reports had been completed for the abnormal temperature or humidity readings for the months of January through April 2016. The infection control department was not notified of the abnormal temperature and humidity readings in the surgical department.

A review of the "temperature log" revealed that the temperature normal readings were to be between 60 and 65 degrees, however, the facility's policy was written that the temperature readings would be between 68 and 73 degrees.

A review of the "temperature log" revealed that the humidity normal readings were to be between 30 and 60%, however, the facility's policy was written that the humidity would be between 20% and 60%.


A review of the facility policy titled, "Humidity/Temperature Control" revealed the following:

"Policy:
To provide guidelines for the environmental control systems in the operating rooms.

Objective:
These rooms will be designed and maintained in accordance with the American Institute of Architects (AlA). The AlA/Association of Perioperative Registered Nurse (AORN) recommends that the Operating Room (O.R.) temperature be maintained between 20C and 23C (68F and 73F) and the relative humidity maintained between 20% and 60%."

PROCEDURE:
1. Relative humidity/temperature levels will be monitored and recorded daily. Relative humidity will typically be maintained between 20% and 60%.

4. A daily log is kept of temperatures and humidity in the operating rooms. When the recommended limits are not in range the log should note that the surgeon was made aware of the low/high humidity level prior to surgical cases.

5. Infection Control Department should be informed of patients receiving surgery when the recommended humidity is out of range to conduct follow-up."

Review of the AORN Perioperative Standards and Recommended Practices, "Temperature should be maintained between 68 degrees F to 73 degrees F (20 degrees to 23 C) within the operating room suite and general work areas in sterile processing.
Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.

Low humidity increases the risk of electro static charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.

Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system."


A review of the facility's policy stated that the facility followed the AORN standards, but the AORN standards stated the humidity will be maintained between 30% and 60% and the facility's policy was written for the humidity to be between 20% and 60%.

An interview with Staff #23 on 05/17/2016 at 3:30 PM confirmed the above findings and that the facility's policy was not followed.

C. monitor the temperature of the fluid warming cabinet for the solutions being used on surgical patients during surgical procedures by the operating room staff for the months of February through May 16, 2016. Also, the surgical staff failed to date the solutions that were placed in the warming cabinet. The surgical department staff were placing surgical prep solution in the warming cabinet. The facility also failed to follow their own policy for warming cabinets.


A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of February 2016 in the Substerile 1 & 2 area, there was a documented temperature reading of 110 degrees on February 24, 2016. There was no documented variance report for a temperature above the normal reading of 104 degrees for warming cabinets.


A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of March 2016 in the Substerile 1 & 2 area, there were documented temperature readings of 106 degrees on March 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, and 12. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.


A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of March 2016 in the Substerile 7 & 8 area, there were documented temperature readings of 106 degrees on March 11, 2016. On March 20, 21, 22, 23, 24, 27, 28, 29, and 30th the temperature readings were documented at 110 degrees. On March 26th the temperature reading was documented at 112 degrees. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.

A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of April 2016 in the Substerile 1 & 2 area, there was a documented temperature reading of 106 degrees on April 23, 2016. There was no documented variance report for a temperature above the normal reading of 104 degrees for warming cabinets.

A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of April 2016 in Substerile 7 & 8 area, there were documented temperature readings of 106 degrees on April 10, 11, 12, 13, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29th. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.

Also, there was another log titled, "Temperature Log-Lower Warmer Compartment" for the same month April 2016 in the same Substerile 7 & 8 area. This log record had documented temperature readings of 110 degrees on April 3, 4, 5, 6, 7, and 8. Also, on this same log record there were temperature readings documented at 108 degrees on April 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, and 29th. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.

A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of May 2016 in the Substerile 1 area, there was a documented temperature reading of 110 degrees on May 1, 2016. This log record also had documented temperature readings of 106 degrees on May 8, 9, 10, 11, 12, and 13th. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.


A review of the log titled, "Temperature Log-Lower Warmer Compartment" for the month of May 2016 in the Substerile 2 area, there were documented temperature readings of 106 degrees on May 8, 9, 10, 11, 12, and 13th. There were no documented variance reports for temperatures above the normal reading of 104 degrees for warming cabinets.

During a tour of the surgical department on 05/16/2016 at 1:30 PM observed in the warming cabinet in various areas of the OR suites the following:

1. Normal Saline 1000 cc bag out of the plastic wrapper lying on the warming cabinet shelf with no date as to how long the bag had been in the warmer.

2. There were 7 Glycine 3000 cc bags in the warming cabinet with no date as to how long the bags had been in the warmer.

3. There were several warmers that had Chloraprep stored in the warming cabinets. Per the manufacturer guidelines Chloraprep should be stored between 15-30 °C (59-86 °F) and avoid freezing and excessive heat above 40 °C (104 °F).

4. One of the warming cabinets had so much linen in the warmer that the door would not close and the linen was touching the floor.

A review of the facility's policy titled, "Warming Cabinets" revealed the following:

"Policy:
The warming cabinets shall be used to warm IV fluids and irrigating solutions according to the manufacturer's guidelines in order to assure patient safety. Some warming cabinets will be used to warm blankets. Do not store IV fluids or irrigating solutions in warming cabinets that contain blankets.

PROCEDURE:

* IV fluid/irrigating fluids will be placed in the warming cabinet and dated with expiration date 14 days from the day they are placed in the warmer. IV solutions should remain in their overwraps until use.
*The circulating RN will verify the date upon removing bottles from the unit to be utilized on the sterile field.
* Fluids kept in a warming cabinet should be rotated on a first in, first out basis.
*The circulating RN will show the scrub person the type of irrigation fluid solution being transferred to the sterile field and will validate the dates placed on the bottles.
*Once the solutions have been removed from the warming cabinet, they must be used within 24 hours and/or discarded. They are NOT to be returned to stock supply or re-warmed.
*Any bottle with a deformity will be discarded.
*The temperature of the warming cabinets containing IV fluids or irrigating solutions will be checked and logged daily. Any variance in temperature will be reported immediately to the charge and/or designee who will in turn notify Biomed,
*The temperature settings for IV fluids should be no greater than 104° F."

An interview with Staff #23 on 05/17/2016 at 3:30 PM confirmed the above findings and that the facility's policy was not followed.


D. monitor and provide a safe and sanitary environment to minimize the transmission of infectious agents in 3 of 7 surgical areas observed. A tour was conducted in the Digestive Disease Center, Day Surgery Unit, Main Surgery area, Perioperative area, PACU (post-anesthesia care unit), Cardiovascular Unit and Catheterization Laboratory.


During a tour of the Digestive Disease Center department on 05/16/2016 at 10:30 AM observed the following:

1. In the patient bathroom clean linen was stacked on an open rolling cart. There was no cover to protect the clean linen. The cart was only 2 feet from the commode and the handwashing sink. This bathroom was available to all patients changing clothes for an endoscopy procedure.

2. In procedure rooms #2, #3, #4, and #6 the cauterization machines were covered in rust. Rust covered metal makes it difficult to clean infectious waste from the surface.

3. In procedure room #2 observed blood and dark colored spots on the floor. The room was ready for the next patient to enter for a procedure.

4. The refrigerator in the recovery room that contained patient's nutrients had brown dried substance on the bottom shelf of the refrigerator.

An interview with Staff #2 on 05/16/2016 at 10:30 AM confirmed the above findings.

During a tour of the Main OR department in the Trauma room on 05/16/2016 at 1:30 PM observed 2 Normal saline 1000 cc bags hanging on IV poles out of the plastic wrappers.

In OR Room #2 observed rust on caster wheels of the mayo stand, prep tray stand, and the back surgery table.

An interview with Staff #23 on 05/16/2016 at 1:30 PM confirmed the above findings.

During a tour of the perioperative area on 05/17/2016 at 8:30 AM observed the following:

While following a patient through a surgical procedure observed in the perioperative area patient #12 was placed in an isolation room due to positive cultures and infective graft site. The patient was in the isolation room, but the isolation room contained all the extra rolling stand computers for the perioperative area. There were approximately 7 computers left in the isolation room.

An interview with Staff #24 and #55 on 05/17/2016 at 8:30 AM confirmed the above findings.